Discrimination and Harassment Complaint Form
The Board declares it to be the policy of this district to provide a safe, positive learning and working environment that is free from bullying, hazing, dating violence, sexual harassment and other discrimination, and retaliation. If you have experienced, or if you have knowledge of, any such actions, we encourage you to complete this form. The Compliance Officer/Title IX Coordinator is there to support you by answering any questions about the report form, reviewing the report form for completion and assisting as necessary with completion of the report.
The Compliance Officer/Title IX Coordinator’s contact information is:
Dr. Beth Williams, Assistant Superintendent
135 Sixth Avenue
Pittsburgh, PA 15229
Name of the Person Making This Report
Address of the Person Making This Report
Phone Number of the Person Making This Report
School Building of the Person Making This Report
If you are not the victim of the reported conduct, please provide the name of the alleged victim:
What is/are the name(s) of the individual(s) you believe is/are responsible for the conduct you are reporting?
The reported individual(s) is/are:
In your own words, please do your best to describe the conduct you are reporting as clearly as possible. Please attach additional pages if necessary:
When did the reported conduct occur? (Please provide the specific date(s) and time(s) if possible):
Where did the reported conduct take place?
Please provide the name(s) of any person(s) who was/were present, even if for only part of the time.
Please provide the name(s) of any other person(s) that may have knowledge or related information surrounding the reported conduct.
Have you reported this conduct to any other individual prior to giving this report?
If yes, who did you tell about it?
If you are the victim of the reported conduct, how has this affected you?
I affirm that the information reported above is true to the best of my knowledge, information and belief.